Washington REC�ivEo
� MAR 0 7 2014
NOTICE OF CLAIM FORM to the �t�16f(����aul, Minnesota
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall cause to be presented to the
governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,place,and
circumstances thereof,and the amount of compensation or other relief demancled." �
Please complete this form in its entirety by clearly typing or printing your answer to each question. If more space is
needed,attach additional sheets. Please note that you will not be contacted by telephone to clarify answers,so provide as
much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a
written acknowledgement once your form is received. The process can take up to ten weeks or longer depending on the
nature of your claim. This form must be signed,and both pages completed. If something does not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
First Name �0�e/� Middle Initial �� Last Name ��-s��n 5�0 y�
Company or Business Name
Are You an Insurance Company? Yes No If Yes,Claim Number?
Street Address o�r7 � �h��!/ �vC # �
City JT �c�N� State /"'� Zip Code 55 �03
Daytime Phone(Co�2�- o ii Cell Phone( ) - Evening Telephone( ) -
Date of Accidend Injury or Date Discovered���� �� �d�3 Time �'��i�pm
Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you
feel the City of Saint Paul or its employees are involved and/or responsibleAfor your damages. 7h t C� o� u
�-. �' �Y.�U N� 6, c�n� �C� i�' nStGGlI iv� /1 ✓�� d� �n A ✓�� O� 7V1L
Ifi !� / �i G . �� ��((�� $�OI a��t/ �. A vICAI �✓ L� . � e i��.e
; ldt �✓ ��tf < me � �� C� !�' 0� �ILr �• '� :+ � Qn
� t 1; kio� r �tl. � ,rc ; n�'s . w a '$ .�. F r �e re �o ro ef�' c ��
e1�d no�' �ollc.�a c�1 a��a h�a,.� ,., ctrr� r I c �t.N � t �✓ ccr.r rv�
� I ro i o✓ �<�h`.,, o,� s�s
Please check the box(es)that most closely represent the reason for completing this form:
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow
❑ My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow
❑ My vehicle was wrongfully towed and/or ticketed ❑ I was injured on City property
❑ Other type of property damage—please specify
�Other type of injury—please specify ��c noi� �lo �+ � i' �
In order to process your claim vou need to include copies of all applicable documents.
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of
your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep a
copy for yourself before submitting your claim form.
O Property damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds
$500.00; or the actual bills and/or receipts for the repairs
O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt
O Other property damage claims: two repair estimates if the damage exceeds $500.00; or the actual bills
and/or receipts for the repairs;detailed list of damaged items
O Injury claims: medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2—Please complete and return both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim. ,
All Claims—please comnlete this section
Were there witnesses to the incident? es No Unknown (circle) �
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes No Unknown (circle)
If yes, what department or agency? ��• �hw� �o�,cc I�.tnt• Case#or report# 13v���3q
Where did the accident or injury take place? Provide street address,cross street, intersection,name of park or facility,
closest landmark,etc. Please be as detailed as possible. If necessary, attach a diagram.
��o Ha��w�-�� A��, S+. pti�� MN
Please indicate the amount you are seeking in compensation ar what you would like the City to do to resolve this claim
to your satisfaction. � 1 DO ��P �.,Li�LdC��rr� c°r'� �/�-t�
Vehicle Claims—please complete this section ❑ check box if this section does not apply
Your Vehicle: Year Make Model
License Plate Number State Color
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
Iniurv Claims please complete this section ❑ check box if this section does not apply
How were you injured?
What part(s)of your body were injured?
Have you sought medical treatment? Yes No Planning to Seek Treatment(circle)
When did you receive treatment? (provide date(s))
Name of Medical Provider(s):
Address Telephone
Did you miss work as a result of your injury? Yes No
When did you miss work? (provide date(s))
Name of your Employer:
Address Telephone
❑ Check here if you are attaching more pages to this claim form. Number of additional pages
By signing this form,you are stating that all information you have provided is true and correct to the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed
Print the Name of the Person who Complete his Form: ,
� � , -
,f
Signature of Person Making the Claim: � ��
;'
Revised February 2011
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Saint Paul Police Department Page , of,
ORIGINAL OFFENSE / INCIDENT REPORT
Complaint Number Reference CN Date and Time of Report
13086539 05/03/2013 13:22:00
Pnmary offense:
BURGLARY-NO FORCED ENTRY,DAY,GARAGE
Primary Reporting Officer. ,JaCObSSOfI, Jeffrey R Name of location/business:
Primarysquad: 32� Locationofincident:620 HAWTHORNE AV E
Secondaryreportingofficer: ST PAUL, MN 55130
Approver. EflgiUtld, Patricia
�istricr: Eastern Date&time of occurrence: 04/12/2013 13:23:00 to
Site: 05/02/2013 13:23:00
Arrest made:
Secondary offense:
Police Officer Assaulted or Injured: Police O�cer Assisted Suicide:
� Crime Scene Processed:
OFFENSE DETAILS
BURGLARY-NO FORCED ENTRY,DAY,GARAGE
Attempt Only: Appears to be Gang Related:
Crime Scene Method 8 Point of Entry
Type: Residentiai prop, unocc Force used: Hid Inside:
Description: Garage Point of entry: DOOI'
Method:
Weapon(s)Used
Motor vehicie
victims
Washington, Robert James
NAMES
Suspect
UNKNOWN
Nicknames or A/iases
Nick Name:
Alias:
AKA First Name: AKA Last Name:
SP5427C5C27804E
Saint Paul Police Department Page 2 of,
ORIGINAL OFFENSE / INCIDENT REPORT
Complaint Number Reference CN Date and Time of Report
13086539 05/03/2013 13:22:00
Primary offense:
BURGLARY-NO FORCED ENTRY,DAY,GARAGE
Details
sex: Male
Race: Whlt2 ��8� Resident Status:
Hispanic: Age: from 25 to 40
Phones
Home: Cell: Contact:
Wo�: Fax: Pager.�
Employment
Occupation: Employer.
Identification
SSN: License or ID#: License State:
Physical Description
US: Metric:
Height: to Build: Hair Length: Hair Color.
Weight: 150
to �7Q Skin: Facia/Hair: Hair Type:
Teeth: Eye Color. B/ood Type:
Offender Information
Arrested: Pursuit engaged: Violated Restraining Order:
DUI: Resistance encountered: `
Condition:
Taken to health care facility: Medical re/ease obtained:
Suspect
UNKNOWN
Nicknames or Aliases
Nick Name:
Alias:
AKA First Name: AKA Last Name:
Details Resident Status:
seX: Male
Race: Whlte DOB:
Hispanic: Age: from 25 to 40
Phones
Home: Cell: Contact:
Work: Fax: Pager.•
SP5427C5C27804E
Page 3 of 7
Saint Paul Police Department
ORIGINAL OFFENSE / INCIDENT REPORT
Complaint Number Reference CN Date and Time of Report
13086539 05/03/2013 13:22:00
Primary offense:
~BURGLARY-NO FORCED ENTRY,DAY,GARAGE
Employment
Occupation: Employer:
Identification
SSN: License or ID#: License State:
Physical Descripfion
US: Metric:
Height: to Build: Hair Length: Hair Color.
Weight: 150 t� 170 Skin: Facial Hair: Hair Type:
Teeth: Eye Color.• B/ood Type:
Offender Informafion
Arrested: Pursuit engaged: Violated Restraining Order.•
DUI: Resistance encountered:
Condition:
Taken to health care facility: Medical re/ease obtained:
Victim Washington, Robert James
620 HAWTHORNE E
ST PAUL, MN 55130
Nicknames or Aliases
Nick Name:
Alias:
AKA First Name: AKA Last Name:
Details
sex: Male
Race: BIaCk ooB� 5/8/1957 Resident Status:
Hispanic: Age: 55 from to
Phones
Home: Cell: Contact: 763-503-4964
Work: Fax: Pager.•
Emp/oyment
Occupation: Emp/oyer.•
Identification
SSN: License or ID#: License State:
SP5427C5C27804E
Page 4 of 7
Saint Paul Police Department
ORIGINAL OFFENSE / INCIDENT REPORT
Complaint Number Reference CN Date and Time of Report
13086539 05/03/2013 13:22:00
Primary offense:
BURGLARY-NO FORCED ENTRY,DAY,GARAGE
Physical Description
US: (vp Metric: No
Height: to Build: Hair Length: Hair Co/or.�
Weight: to Skin: Facial Hair. Hair Type:
Teeth: Eye Color. Blood Type:
Victim Informafion
Type: IfIdIVIdU81 Can Identify Offender: Np Willing to Press Charges: YeS
Condition:
Taken to health care facility: Np Medical release obtained: NO
Witness Lee, Cory Anthony
615 MARYLAND E Apt 1
ST PAUL, MN 55130
Nicknames or Aliases
Nick Name:
Alias:
AKA First Name: AKA Last Name:
Details
Sex:
Race: Black DOe: 10/15/1976 Resident Status:
Hispanic: Age: 36 from to
Phones
Home: Ce�l: Contact: 651-206-4270
Wory�: Fax: Pager.•
Employmeni
Occupation: Employer.•
Identification
SSN: License or ID#: License State:
SP5427C5C27804E
Page 5 of 7
Saint Paul Police Department
ORIGINAL OFFENSE / INCIDENT REPORT
Complaint Number Reference CN Date and Time of Report
13086539 05/03/2013 13:22:00
Primary offense:
BURGLARY-NO FORCED ENTRY,DAY,GARAGE
SOLVABILITY FACTORS
Suspect can be Identified: 81'�
Photos Taken: Stolen Property Traceab/e:
Evidence Turned In: Property Tumed In:
Related Incident:
Lab
Biological Analysis: Fingerprints Taken:
Narcotic Analysis: Items Fingerprinted:
Lab Comments:
PROPERTY
ITEM#1
Type oiLoss: Stolen Date of�oss: 4/12/2013 �ocation�ost: 620 hawthorne
Owner.� Washington, Robert Date Recovered: Location Recovered.•
Model#: Quantity: 4 Serial#:
Article Type/Item: Other property / Vehicle Parts Tota/value: $1,800.00
oescription: Tire rims VCT (two of the rims had missing center caps)
Turned in at: Locker ID#: Lab exams:
ITEM#2
rype of�oss: Stolen
Date of�oss: 4/12/2013 �ocarion�ost: 620 Hawthorne
Owner. �/ash'tngton, Robert Date Recovered: Location Recovered:
� Model#: Quantity.� � Senal#:
Artic�e Type/�tem: Other property / Miscellaneous items Total value: $900.00
�escr;Pt�on: Flatbed trailer
Tumed in at: Locker ID#: Lab exams:
SP5427C5C27804E
Page 6 of 7
Saint Paul Police Department
ORIGINAL OFFENSE / INCIDENT REPORT
Complaint Number Reference CN Date and Time of Report
13086539 05/03/2013 13:22:00
Primary offense:
BURGLARY-NO FORCED ENTRY,DAY,GARAGE
ITEM#3
Type of Loss: StOlell Date of Loss: 4/12/2013 �ocation�osr: 620 Hawthorne
owner: Washington, Robert Date Recovered: Location Recovered:
Model#: Quantity.� 2 Serial#:
Article Type/Item: Othef property / Tools Total value: $600.00
�escriprion: 1-Craftsman lawnmower1-unk make lawnmower
Turned in at: Locker ID#: La6 exams:
ITEM#4
rype or�oss: Stolen Date of Loss: 4/12/2013 �ocarion Losr: 620 Hawthorne
Owner. Washington, Robert Date Recovered: Location Recovered:
Model#: Quantity.� � Serial#:
Article Type/Item: Oth2�pfOpem/ / Toois Total value: $150.00
Description: �J�k 81f COf11pf2SS01'
Tumed in at: Locker ID#: Lab exams:
ITEM#5
Type of Loss: St012f1 Date of loss: 4/12/2013 �ocation�ost: 620 Hawthorne
Owner.� Washington, Robert Date Recovered: Location Recovered:
Model#� Quantity.� � Serial#:
Article Type/Item: Other propetty / Tools Tota�va�ue: $150.00
oescripr;on: Heavy duty hydraulic floorjack
Turned in at: Locker ID#: Lab exams:
ITEM#6
ryPe or�oss: Stolen
Date of�oss: 4/12/2013 �ocation C.ost: 620 Hawthorne
Owner. WashingtOn, Robert Date Recovered: Location Recovered.�
Model#: Quantity: 1 Serial#:
,artic�e TyPeiirem: Other property / Tools Total value: $100.00
Description: Red dolly
Turned in at: Locker ID#: Lab exams:
SP5427C5C27804E
Page 7 of 7
Saint Paul Police Department
ORIGINAL OFFENSE / INCIDENT REPORT
Complaint Number Reference CN Date and Time of Report
13086539 05/03/2013 13:22:00
Primary offense:
BURGLARY-NO FORCED ENTRY,DAY,GARAGE
Participants:
Person Type: Name: Address: Phone:
Suspect
Suspect
Victim Washington, Robert James 620 HAWTHORNE E
ST PAUL, MN 55130
Witness Lee, Cory Anthony 615 MARYLAND E Apt 1
ST PAUL, MN 55130
NARRATIVE
No ICC video squad 1188
��.
On 5/3/2013 at 1252 hours I was sent to 620 Hawthorne on a garage burglary. Upon arrival I met victim,
Washington, Robert James DOB 5/8/1957 620 Hawthorne#1 phone 763-503-4964. Washington stated that he
was incarcerated sometime around 4/12/2013. Washington stated that at the time the police searched his
garage and failed to secure it. Washington stated that on 5/2/2013 he discovered that several items were
removed from his garage. Witness Lee, Cory Anthony 615 Maryland #1 DOB 10/15/1976 cell# 651-206-4270
told me that about 3 weeks ago he observed 2 skinny white males 25 to 40 years old taking Washington 's
trailer and tools out of the garage. Lee did not know that Washington was incarcerated. Lee stated that the 2
white males were driving a gray 94-98 Buick 98. Total value of loss $3700.00. Washington stated that he has
seen a similar vehicle at his duplex visiting the residents in apartment#2
Washington then related that on 5/2/2013 at 2250 hours he was at the BP at Old Hudson and Ruth when
he saw a vehicle license plate 354JGW. Washington stated that this vehicle had his stolen rims on it.
Washington stated that the two front rims were missing the center caps as were his. Washington stated that
as he started to approach the vehicle to look at the rims the driver a white male reached in and put something
on his side. Washington believed it to be a gun so he walked away.
PUBLIC NARRATIVE
�� Garage burglary at 620 Hawthorne.
SP5427C5C27804E
Page � of 4
Saint Paul Police Department
SUPPLEMENTAL OFFENSE / INCIDENT REPORT
�'Complaint Number Reference CN Date and Time of Report
13086539 11/09/2013 13:16:00
Primary offense:
BURGLARY-NO FORCED ENTRY,DAY,GARAGE
Primary Reporting Officer.• QUBSt, David A Name oflocation/business:
Primary squad: 254 location of incident:ACKER ST E &JACKSON
Secondary reporting officer: FIIIOWICh, Shawn J ST PAUL, MN 55117
Appro�er.� Grahek, Jon
District: Central Date&time of occurrence: 11/09/2013 13:16:00 t�
Site: 11/09/2013 13:16:00
Arrest made:
Secondary offense:
Police O�cerAssaulted orinjured: Police O�cerAssisted Suicide:
Crime Scene Processed:
OFFENSE DETAILS
�BURGLARY-NO FORCED ENTRY,DAY,GARAGE
Attempt Only: Appears to be Gang Re/ated:
Weapon(s)Used
Motor vehicle
NAMES
Other Kapaun, Judy Patricia
105 SYCAMORE AV E
ST PAUL, MN 55117
Nicknames or Aliases
Nick Name:
Alias:
AKA First Name: AKA Last Name:
Details
sex: Female Race: White
DOe: 1/5/1946 Resident Status:
Hispanic: Age: 67 from to
Phones
Home:
Ce11: 651-290-0097 Contact
Work: Fax: Pager.
SP5427C5C27804E
Page 2 of 4
Saint Paul Police Department
SUPPLEMENTAL OFFENSE / INCIDENT REPORT
Complaint Number Reference CN Date and Time of Report
13086539 11/09/2013 13:16:00
Primary offense:
BURGLARY-NO FORCED ENTRY,DAY,GARAGE
Employment
Occupation: Employer.
Identificafion
SSN: License or ID#: License State:
Victim Washington, Robert James
620 HAWTHORNE
ST PAUL, MN 55109
Nicknames or Aliases
Nick Name:
Alias:
AKA First Name: AKA Last Name:
� Details
sex: Male
Race: Black DOe: 5/8/1957 Resident Status:
Hispanic: Age: 56 from to
Phones
Home: Ce�/:612-638-8811 Contact:
Work: Fax: Pager.•
Employment
Occupation: Employer.�
Identification
SSN: License or ID#: License State:
Physical Description
us: Yes Metric: Np
Height: 6Q to auiid: Slender HairLength: Sh01't h21t' HairColor: BIBCk
Weight: �$� to Skin: Facial Hair.� Hair Type: CUfly
Teetn:Capped Eye Color.� BfOWn Blood Type:
Victim Information
Type: Individual
Can Identify Offender.• Np Willing to Press Charges: NO
Condition: COf1SCI0Us
Taken to health care facility: (�Jp Medical release obtained: NO
lnjuries
Type Location
SP5427CSC27804E
Saint Paul Police Department Page 3 of4
SUPPLEMENTAL OFFENSE / INCIDENT REPORT
Complaint Number Reference CN Date and Time of Report
13086539 11/09/2013 13:16:00
Primary offense:
BURGLARY-NO FORCED ENTRY,DAY,GARAGE
None Other
SOLVABILITY FACTORS
Suspect can be Identified: By�
Photos Taken: YgS Stolen Property Traceable:
Evidence Tumed In: Property Tumed In:
Related Incident:
Lab
Biological Analysis: Fingerprints Taken:
Narcotic Analysis: Items Fingerprinted:
Lab Comments:
Participants:
.Person Type: Name: Address: Phone:
Other Kapaun, Judy Patricia 105 SYCAMORE AV E
ST PAUL, MN 55117
Victim Washington, Robert James 620 HAWTHORNE
ST PAUL, MN 55109
NARRATIVE
On 11/09/2013 at 1000 hours, Squad# 254 (QuasUFiliowich) was dispatched to Acker and Jackson to meet a
party that found his trailer that was stolen from 620 Hawthorne Ave East on 5-3-2013.
Upon arrival we were met by comp/vic: ROBERT JAMES WASHINGTON. He stated that his trailer was stolen
from 620 Hawthorne on 5-3-13 and now he sees it in the rear of 105 East Sycamore by a garage. He stated
that he recognized it by a tire and a jack that they have to put on it from another trailer and it should have red
carpet in the bed of it.
We went to the front door of 105 East Sycamore to talk with the owner of the house. Upon arrival we spoke to
the owner JUDY PATRICIA KAPAUN (1-5-46) she said that she had no idea who's trailer it was and could not
tell us how long it has been parked by he garage.
We told her that the trailer had been stolen it in burglary and we were going to hand it of to the owner. KAPAUN
she said that she would have no problem with the owner getting their property back.
The trailer was turned over to the owner ROBERT WASHINGTON.
List of Photos for CN 13086539:
SP5427C5C27804E
Page 4 of 4
Saint Paul Police Department
SUPPLEMENTAL OFFENSE / INCIDENT REPORT
Complaint Number Reference CN Date and Time of Report
13086539 11/09/2013 13:16:00
Primary offense:
BURGLARY-NO FORCED ENTRY,DAY,GARAGE
1. 13086539-11092013_110940-BURGLARY-1.jpg - TRAILER THAT WAS I/D BY THE OWNERS
2. 13086539-11092013_110945-BURGLARY-2.jpg - THE JAKE ON THE NECK OF THE TRAILER THAT
WAS ADDED BY THE OWNER
3. 13086539-11092013_110958-BURGLARY-3.jpg - THE BED OF THE TRAILER WITH THE RED CARPET
THAT WAS ADDED BY OWNER
4. 13086539-11092013_111006-BURGLARY-4.jpg - TAIL LIGHTS ON TRAILER THAT WERE MOVED
FROM BOTTOM OF THE TRAILER TO THE SIDES OF THE TRAILER
5. 13086539-11092013_111017-BURGLARY-5.jpg - REAR OF TRAILER
6. 13086539-11092013_111030-BURGLARY-6.jpg - TRAILER
7. 13086539-11092013 124402-BURGLARY-7.db - .
The labeled photos were TRANSFERRED to the Media Vault.
PUBLIC NARRATIVE
SUPPLEMENT REPORT.
SP5427CSC27804E
Page 1 of 1
Saint Paul Police Department
SUPPLEMENTAL OFFENSE / INCIDENT REPORT
Complaint Number Reference CN Date and Time of Report
13086539 05/07/2013 12:07:00
Primary offense:
BURGLARY-NO FORCED ENTRY,DAY,GARAGE
Primary Reporting O�cer. KCUS2, Robert J Name of location/business:
Primary squad: Location of incident:620 HAWTHORNE AV E
Secondary reporting oificer.� ST PAUL, MN 55130
Approver.�
�istrict: Eastern Date&time of occurrence: 04/12/2013 13:23:00 to
Site: 05/02/2013 13:23:00
Arrest made:
Secondary offense:
Police OfficerAssaulted or Injured: Police O�cerAssisted Suicide:
Crime Scene Processed:
NARRATIVE
i This case was reviewed and I noted no information to immediately identify any suspects or solvability factors to
`further the investigation. I called and left a voice message for the victim advising of the case status and my
contact information. I also requested a return call with any new information or questions.
PUBLIC NARRATIVE
SP5427CSC27804E